NCLEX-RN
NCLEX RN Medical Surgical Questions and Answers Questions
Extract:
Question 1 of 5
The nurse uses a Doppler ultrasound device to assess the client's lower extremities. In addition, the nurse calculates the ankle-brachial index to estimate stenosis of the:
Correct Answer: A
Rationale: The ankle-brachial index (ABI) measures the ratio of ankle to brachial systolic blood pressure to assess arterial stenosis in the lower extremities. A low ABI indicates arterial narrowing, typical in PVD. It does not assess the aorta, carotid, or veins.
Question 2 of 5
The nurse should instruct a client who has been diagnosed with vasospastic disorder (Raynaud's phenomenon) to:
Correct Answer: C
Rationale: Wearing gloves when handling ice or frozen foods prevents cold-induced vasospasm in Raynaud's. Cold water worsens symptoms, light garments are insufficient in cold temperatures, and living in a cold climate increases episode frequency.
Question 3 of 5
A nurse is providing wound care to a client 1 day after the client underwent an appendectomy. A drain was inserted into the incisional site during surgery. Which action should the nurse perform when providing wound care?
Correct Answer: D
Rationale: When providing wound care, the nurse should clean the area around the drain moving away from the drain to prevent introducing pathogens into the wound. Leaving the incision open, removing the drain, or irrigating are not appropriate without specific orders. CN: Physiological adaptation; CL: Synthesize
Question 4 of 5
When developing a teaching plan for a client who is prescribed acetaminophen (Tylenol) for muscle pain, which information should the nurse expect to include? Select all that apply.
Correct Answer: A,B,C
Rationale: Acetaminophen is safe for aspirin allergies, does not affect platelets, and causes minimal gastric distress. It has weak anti-inflammatory effects and does not require INR monitoring.
Question 5 of 5
A client who has undergone a subtotal thyroidectomy is subject to complications in the first 48 hours after surgery. The nurse should obtain and keep at the bedside equipment to:
Correct Answer: D
Rationale: Tracheotomy equipment is essential due to the risk of airway obstruction from swelling or hemorrhage post-thyroidectomy.